Trauma Flashcards
Causes of shock
Bleeding (hypovolemic hemorrhagic)-CVP low, empty veins
pericardial tamponade- CVP high, distended veins, trauma, no respiratory distress
Tension pneumothorax- CVP high, distended veins, trauma, respiratory distress, unilateral no breath sounds, hyperresonance, tracheal displacement.
Clinical signs of shock
Low BP (<0.5mL/kg/h Cold, shivering, sweating, thirsty, and apprehensive
Treatment of hemorrhagic shock
Volume replacement-2L LR w/ packed RBCs until 0.5 UOP
Surgery to stop bleeding
Management of pericardial tamponade
Clinical dx confirm with u/s
Pericardialcentesis, tube, pericardial window, or thoracotomy
Management of tension pneumothorax
Clinical dx
Catheter into affected pleural space
Follow with chest tube connected to underwater seal
Other causes of hypovolemic shock
Burns
Peritonitis
Pancreatitis
Massive diarrhea
Intrinsic cardiogenic shock
Caused by massive myocardial damage- MI or myocarditis
Tx with circulatory support
NO fluids
Vasomotor shock
Anaphylactic rxn or high spinal transection
Circulatory collapse in pink warm patient
CVP low
Restore peripheral resistance
Linear skull fracture
Left alone if closed
Open req closure
Comminuted or depressed go to OR
Head trauma w/LOC
Always get CT looking for intracranial hematoma
If negative can go home with wakings
Basilar skull fracture
Raccoon eyes Rhinorrhea Otorrhea Ecchymosis behind ears Assess integrity if C spine w/ CT nasal endotracheal intubation AVOIDED
Neurological damage from trauma
Initial blow
Hematoma- displace structures
Increased ICP
Acute epidural hematoma
Trauma, LOC, lucid interval, gradual lapse into coma
Fixed dilated pupil, contra lateral hemiparesis, decerebrate
CT shows biconvex lens shaped hematoma
Tx emergency craniotomy
Acute subdural hematoma
Same but worse trauma and more severe damage
Not fully awake or asymptomatic at any point
CT shows semilunar crescent shaped hematoma
If midline shift, can craniotomy but bad prognosis
Prevent ICP increase: monitoring, elevate HOB, hyperventilate to pCO2 35, avoid fluid overload, mannitol, furosemide
Sedation to decrease brain activity
Hypothermia to reduce oxygen demand
Diffuse axial injury
Severe trauma
Cat shows diffuse blurring of gray-white interface and multiple small punctuate hemorrhages
Without hematoma no surgery
Prevent increased ICP
Chronic subdural hematoma
Occurs in very old or severe alcoholics
Shrunken brain rattles around tearing venous sinus
Over days/weeks mental fxn declines
CT dx and surgical evacuation tx
Hypovolemic shock and intracranial bleed
CANNOT HAPPEN
Penetrating neck trauma
Surgical exploration if hematoma, deteriorating vital signs or esophageal/tracheal injury
Explore GSW of middle zine
Selective neck trauma approach
GSW upper zone: arteriography
GSW base of neck: arteriography, water soluble esophagogram, esophagoscopy, and bronchoscope
Neck stab wounds
Upper and middle zones observed
Severe blunt trauma to neck
C spine eval
CT best
Hemisection, brown sequard
Clean cut injury
Paralysis and loss of proprioception distal to injury ipsilaterally
Loss of pain perception contralateral
Anterior cord syndrome
Seen with burst fracture of vertebrae
Loss of motor fxn, pain, and temperature bilaterally
Preserves vibratory and positional sense
Central cord syndrome
Elderly with forced hyperextension of neck- rear ended
Paralysis and burning pain upper extremities
Rib fracture
Can be deadly in elderly
Pain->atelectasis->pneumonia
Tx w/ nerve block and epidural catheter
Pneumothorax
Penetrating trauma or rib fx stab
SOB, unilateral loss of breath sounds, hyperresonance
Get CXR then place chest tube
Hemothorax
Penetrating wound or rib fx
Dull to percussion
CXR
Evacuate with chest tube to prevent empyema
Thorocotomy if systemic vessel bleed
Surgery if >1500ml in chest tube on insertion, or >600ml over 6 h
Severe blunt chest trauma
Hidden injuries
Monitor blood gas and CXR for pulmonary contusion
Cardiac enzymes and EKG for myocardial contusion
Always look for traumatic aortic transection
Sucking chest wound
Flap sucks air
Lead to tension pneumothorax
Tx occlusive dressing
Flail chest
Multiple rib fx allows wall segment to cave in and bulge out
Underlying pulmonary contusion
Contusion sensitive to fluids so restriction and diuresis
Monitor blood gas
If ventilated, need bilateral chest tubes
R/o aortic transection
Pulmonary contusion
Deteriorating blood gasses and white out of lungs on CXR
can appear early or late
Tx fluid restriction and diuresis
Myocardial contusion
Suspected in stern all fx
EKG detects and cardiac enzymes
Tx complications like arrhythmia
Traumatic rupture of diaphragm
Bowel in chest on exam and CXR
Always on left side
Eval with laparoscopy with surgical repair
Traumatic rupture if aorta
Occurs at junction of arch and descending
Deceleration injury
Asymptomatic until hematoma I’m adventitia blows up and kills
Always suspicious esp if broken 1st rib, scapula or sternum; wide mediastinum
Transesophageal echo, spiral CT, MRI angio
Traumatic rupture of trachea or bronchus
Subcutaneous emphysema in upper chest, lower neck, or air leak
CXR shows air in tissue, bronchoscope shows lesion and allows intubation beyond lesion
Surgical repair
Air embolism
Sudden death in chest trauma intubated on respirator
Also when subclavian vein open to air
Tx: cardiac massage w/ pt LT side down
Prevent w/ trendelenburg when entering great vessels
Fat embolism
Respiratory distress
Multiple fx including long bones
Petechial rash in axilla and neck, fever, tachycardia, low platelets
Tx w/ respiratory support
GSW to abdomen
Exploratory laparotomy
Enter or exit below nipple assumed abdominal
Abdominal stab wound
If clear penetration, unstable vitals, or peritoneal irritation then laparotomy
Otherwise digital exploration of wound
Blunt trauma to abdomen
ExLap if signs of peritoneal irritation
Otherwise determine if bleeding
Look for signs of internal bleeding
Signs of internal bleeding in blunt trauma patient
Drop on BP w fast threads pulse, low CVP, and low, UOP
Signs of shock when loss 25-30% blood volume
Can be into pericardial sac, pleural cavity, abdomen, thighs and pelvis
Diagnosis of intraabdominal bleeding
CT scan only if hemodynamically stable
Response to fluid resuscitation determines surgery
If unstable, diagnostic peritoneal lavage or FAST
Ruptured Spleen
Most common significant intraabdominal bleed in blunt trauma
Hints: fx LT rib
Every effort made to salvage
If removed, vaccinate pneumococcus, H. Influenza, and meningococcus
Intraoperative coagulopathy
Long abdominal surgery for multi trauma and lots of transfusions
Tx w/ platelet packs and FFP 10 units each
If also hypothermia and acidosis then stop lap and temporary close until correct issues
Abdominal compartment syndrome
Lots of fluids/blood in long laparotomy
Tissues swollen and closure without tension impossible
Temporary cover over contents then close later
If you close anyway, get distention, retention sutures cutting thru tissue, hypoxia b/c can’t breathe and renal failure from vena cava compression
Then abdomen must be opened and put temporary cover
